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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 i <br /> n u f—� P 0 BOX 2009, STOCKTON, CA 95201 <br /> ( `I t <br /> r PERMIT EXPIRES 1 YEAR FROM D T ED a <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name. �0--[� _. Address Phone ,0 <br /> Contractor. GG Address - - d6Yl. License No�� —Phone <br /> i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> i PUMP INSTALLATION ❑ 4 SYSTEM REPAIR >/ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ' iNTENDED USE } TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 4 <br /> n Industrial /E)-.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private f ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public 1-1 Other C1 Delta If Depth of Grout Seal Type of Grout <br /> I I Irrigation r Approx. Depth J I Eastern.' Surface Seal Installed by <br /> Repair Work Done of Pump H.P. ^ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PET. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines_ Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation _. I Property Line <br /> SEEPAGE PITS I 1 DepthSi. Number <br /> SUMPS L) Distance to nearest: e J Well 1 Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application'and thatrhe work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County * , f a,, <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> j certifies the following: "1 cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." Try <br /> r The applican call for all required ' spections t omplate drawing on re rse side, �} <br /> Signed X Title: r� t0 Date: V <br /> �1 FDR—DEPARTMENT USE ONLY <br /> Application Accepted by Date Z 1 ~� Area 0 <br /> Pit or Grout Inspection by Date Final Inspection by Date g <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEEINFO MOUUNNT DUE AMOUNT REMITTED ASR RECEIVED BY PATE PERMIT'NO. <br /> . EH 13.241REV.r/nsi �]i; i� � <br /> EH;{,2a v <br />